Implementation of WHO Guidelines on the Management of Severe Malnutrition in South Africa and Ghana

In the past, Field Exchange has addressed issues faced by international humanitarian agencies in phasing out emergency therapeutic feeding programmes and leaving behind improved and sustainable capacity for treatment of severe malnutrition. The study summarised below provides additional evidence that at least in non-emergency situations, improved and sustainable practices can be promoted (Ed).

The study set out to investigate the problems, benefits, feasibility and sustainability of implementing World Health Organisation (WHO) guidelines on the management of severe malnutrition2. A postal questionnaire was sent to 12 African hospitals inviting them to participate. Five hospitals were evaluated and two were selected to take part in the study - a district hospital in South Africa (Battor Hospital) and a mission hospital in Ghana (Mapulaneng Hospital). At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation.

Implementation of most of the main principles of the WHO severe malnutrition guidelines was feasible, sustained over a oneyear period, and affordable to the institutions (see table 2). Although relatively labour intensive, the process was successful because hospital staff were involved in planning the changes from the outset, logistical limitations were acknowledged and local modifications to the generic approach were developed. The success can also be attributed to the enthusiasm of the resident paediatricians and the follow up by the visiting paediatrician. As the resources for implementation came from the hospital budgets (except for a supply of mineral and vitamin pre-mix), financial sustainability is likely.

Whether the WHO guidelines, once implemented, are effective is another important and relevant question. At Battor, the mortality was unchanged, possibly because diagnoses of severe malnutrition were more precise during the study year - this is supported by a decrease in the number of admissions classified as severely malnourished from 81 at the beginning, to 39 during the study. At Mapulaneng, the mortality halved. This may have been because all cases of severe malnutrition, not only those with complications, were admitted, as suggested by the increase from 29 cases pre-study to 125 cases during the study. Also, the study was not blinded so some bias in the reporting may have occurred during the study year.

Comparisons aside, some would still regard the 18% fatality rate from severe malnutrition at both hospitals during the study period as unacceptably high, considering the guidelines target mortality rates of 5-10%. Guideline components that were not implemented or sustained may have been crucial to achieving further decreases in case-fatality rates. Furthermore, guideline practices believed to be in place may have been implemented inconsistently or poorly in reality. Also, the influence of HIV on malnutrition mortality was not measured specifically. The primary cause of death in some cases was probably advanced acquired immunodeficiency syndrome (AIDS), in which case the deaths would not have been preventable.

Hospital staff questioned the evidence base of some of the guideline components and felt that the evidence behind certain recommendations - such as the single approach for managing marasmus and kwashiorkor, feeding frequencies, routine antibiotics, and requirements of micronutrients other than vitamin A, folic acid and zinc - was inadequate. Documentation of the technical basis of these specific recommendations, or research to provide the necessary evidence, would promote wider acceptance of the guidelines.
The study intentionally selected two general hospitals that seemed to have a good chance of implementing the guidelines. Although the findings cannot be generalised to all small hospitals in Africa, the study gives an idea of what may or may not be feasibly implemented with a minimum of intervention. It is difficult to predict whether similar African hospitals would have the same success in improving care management practices by following the guidelines, particularly without external consultant support. Conversely, more intensive input and support might allow implementation of all components of the guideline but with less assurance of sustainability.

The authors of the study concluded that wider implementation of the guidelines in similar settings is possible but that the guidelines could be improved by including additional information on how to adapt specific components to local situations. Furthermore, additional information is needed about certain components of the guidelines and their impact on mortality.

Table 1 Summary of the feasibility and sustainability of the main components of the WHO guidelines for the management of severely malnourished children

Category

Battor and Mapulaneng Hospital

Mapulaneng Hosptial

Battor Hospital

Feasible and sustained

. Routine admission of all severely malnourished children
. Using key signs, oedema of both feet or severe visible wasting, for the diagnosis
. Measurement of height and calculation of weight-for-height
. Measures against hypoglycaemia, e.g. early feeding on admission, nasogastric tube feeding when necessary
. Measures against hypothermia, e.g. blankets, heaters, keeping the children dry
. Restricting the use of intravenous fluids only to those with shock or severe dehydration
. Preparation and use of starter (75 kcal/100 ml) and catch-up (100 kcal/100 ml) formulae
. Delaying the administration of supplemental iron

Triage, urgent assessment and management

. Allowing mothers to stay with the children all day and night
. Routine administration of oral antibiotics to those without complications

Feasible with adaptation or special provision

Frequent feeding, all day and night Supplemental electrolytes, minerals, and vitamins